ObjectiveTo summarize the application status and prospect of laparoscopic pancreaticoduodenectomy (LPD).MethodThe relevant literatures about studies of LPD at home and abroad were reviewed.ResultsLPD was a difficult operation, mainly suitable for pancreatic head and periampullary benign and malignant tumors. With the development of laparoscopic techniques in recent years, LPD combined the superior mesenteric vein and portal vein resection and reconstruction, or combined multi-visceral resection was feasible, but the survival benefit of LPD with arterial resection and reconstruction and extended lymph node dissection remained to be discussed. At present, there was no clear requirement on the way to reconstruct the pancreatic fluid outflow tract, but the pancreaticojejunostomy for digestive tract reconstruction was chose by the most surgeons. The most studies had confirmed that LPD was minimally invasive and had a short-term prognosis that was not inferior to that of open pancreaticoduodenectomy. However, the results of large sample analysis about long-term survival rate and oncology results were lacking, so it was difficult to judge the advantages and disadvantages of long-term prognosis of the two methods.ConclusionsLPD is a safe, feasible, reasonable, and effective surgical method. With improvement of laparoscopic technology, LPD is expected to become a standard operation method for treatment of pancreatic head cancer and periampullary carcinoma, and oncology benefits of LPD will be further confirmed in future by large-sample clinical randomized control trials and studies of long-term prognosis follow-up.
Objective To investigate the effect of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer. Methods The clinical data of a patient with pancreatic cancer admitted to the Beijing Tsinghua Changgung Hospital in December 2021 who underwent pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein were analyzed retrospectively. The patient was a 77-year-old man who complained of “epigastric pain for 1 month and pancreatic mass was found for 1 week”. After admission, the patient was diagnosed with pancreatic cancer through inspection, and then the surgery was required. Preoperative examination and intraoperative exploration confirmed that the junction of portal vein, superior mesenteric vein, and spleen vein was invaded by tumor. In addition, the length of the invaded vessels measured by preoperative 3D reconstruction image was 5.5 cm, and the distance between the broken end of portal vein and the broken end of superior mesenteric vein measured was 4.5 cm during the operation. After tumor and vessels were resected, vascular anastomosis could not be performed directly. After accurate evaluation, pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein was performed. The operative time was 11 h, and the intraoperative blood loss was 400 mL. After the operation, the routine treatment was performed in ICU and was transferred to the general ward on the 7th day. Postoperative laboratory tests were performed to monitor liver function changes routinely, and imaging examination were was performed to monitor portal venous system blood flow. Results Postoperative complications such as biliary fistula, pancreatic fistula, hemorrhage, infection and thrombosis were not occurred. Postoperative pathological diagnosis: pancreatic ductal adenocarcinoma, medium-low differentiation. Enhanced CT reexamination on the 2nd and 13th day after the operation showed that the blood flow at the junction of portal vein, superior mesenteric vein and splenic vein of the common iliac vein allograft was unobstructed, and there was no stenosis or thrombosis at each anastomosis. Conclusions The application of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer is safe and feasible. The short-term efficacy is satisfactory, and long-term prognosis remains to be further observed.
ObjectiveTo summarize the current status and update of the use of medical imaging in risk prediction of pancreatic fistula following pancreaticoduodenectomy (PD).MethodA systematic review was performed based on recent literatures regarding the radiological risk factors and risk prediction of pancreatic fistula following PD.ResultsThe risk prediction of pancreatic fistula following PD included preoperative, intraoperative, and postoperative aspects. Visceral obesity was the independent risk factor for clinically relevant postoperative pancreatic fistula (CR-POPF). Radiographically determined sarcopenia had no significant predictive value on CR-POPF. Smaller pancreatic duct diameter and softer pancreatic texture were associated with higher incidence of pancreatic fistula. Besides the surgeons’ subjective intraoperative perception, quantitative assessment of the pancreatic texture based on medical imaging had been reported as well. In addition, the postoperative laboratory results such as drain amylase and serum lipase level on postoperative day 1 could also be used for the evaluation of the risk of pancreatic fistula.ConclusionsRisk prediction of pancreatic fistula following PD has considerable clinical significance, it leads to early identification and early intervention of the risk factors for pancreatic fistula. Medical imaging plays an important role in this field. Results from relevant studies could be used to optimize individualized perioperative management of patients undergoing PD.
ObjectiveTo evaluate efficacy and safety of early anticoagulation therapy with low molecular weight heparin (LMWH) in prevention of venous thromboembolism (VTE) after pancreatoduodenectomy (PD).MethodsThe patients who received PD in our hospital from January 2017 to December 2018 were collected retrospectively, then were divided into the anticoagulant group and the non-anticoagulant group. The operation time, intraoperative blood loss, tumor property, coagulation function indexes such as prothrombin time (PT), PT activity (PTA), fibrinogen (FIB), activated partial thromboplastin time (APTT), thrombin time (TT), and D-dimer (DD), platelet (PLT), VTE, bleeding related complications etc. were compared between the two groups.ResultsA total of 103 patients underwent PD were included in this study, including 52 patients in the anticoagulant group and 51 patients in the non-anticoagulant group. There were no significant differences in the baseline data such as the gender, age, and preoperative coagulation function indexes, etc. between the two groups (P>0.05). The incidence of VTE in the anticoagulant group was lower than that in the non-anticoagulant group (13.5% versus 47.1%, P<0.001). There was no significant difference in the incidence of bleeding between the anticoagulant group and the non-anticoagulant group (9.6% versus 7.8%, P>0.05). There were no statistically significant differences in the coagulation indexes between the two groups before operation and day 1 after operation (P>0.05). On day 8 after operation, the FIB and DD values of the anticoagulant group were significantly lower than those of the non-anticoagulant group (P values were 0.040 and 0.002, respectively). A comparison of different phases in the same group on coagulation indexes between day 8 and day 1 after surgery showed that there were statistically significant differences (P<0.05), the changes of all indexes were within the normal range.ConclusionThe results of this study indicate that LMWH administered at 24 h after PD could decrease incidence of VTE and don’t increase risk of bleeding.
Objective
To summarize preliminary experience of laparoscopic pancreaticoduodenectomy for periampullary carcinoma.
Method
The clinical data of patients with periampullary carcinoma underwent laparoscopic pancreaticoduodenectomy from July 2016 to September 2016 in the Shengjing Hospital of China Medical University were analyzed retrospectively.
Results
Two patients underwent complete laparoscopic pancreaticoduodenectomy, 2 patients underwent laparoscopic resection and anastomosis assisted with small incision open. The R0 resection and duct to mucosa pancreaticojejunal anastomosis were performed in all the patients. The operative time was 510–600 min, intraoperative blood loss was 400–600 mL, postoperative hospitalization time was 15–21d, postoperative ambulation time was 6–7 d. Three cases of pancreatic fistula were grade A and all were cured by conservation. No postoperative bleeding, delayed gastric emptying, intra-abdominal infection, and bile leakage occurred. The postoperative pathological results showed that there was 1 case of pancreatic head ductal adenocarcinoma, 1 case of cyst adenocarcinoma of pancreas uncinate process, 1 case of papillary carcinoma of duodenum, and 1 case of terminal bile duct carcinoma.
Conclusion
The preliminary results of limited cases in this study show that laparoscopic pancreaticoduodenectomy has been proven to be a safe procedure, it could reduce perioperative cardiopulmonary complications, its exhaust time, feeding time, and postoperative ambulation time are shorter, but its operative complications could not be reduced.
ObjectiveTo discuss the current status and progress of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD).MethodThe related researches about DGE after PD in recent year were searched and reviewed.ResultsThe etiology and pathogenesis of DGE had not yet been fully elucidated. There were various risk factors, such as the surgical trauma, advanced age, diabetes, and with other abdominal complications. The pylorus preserving PD didn’t increase the risk of DGE. The pylorus ring resection, anterior colon, Braun anastomosis, and minimally invasive surgery were beneficial for reducing DGE. Although there was no obvious progress in the treatment of DGE at home and abroad, the majority of patients could be cured by the symptomatic conservative treatment.ConclusionsPrevention is a main strategy for DGE after PD. Application of enhanced recovery after surgery might be a key to solve problem in clinical, but further research is needed.
ObjectiveTo investigate the clinical effect of end-to-side binding pancreaticojejunostomy.MethodsFrom March 2009 to December 2019 , 70 patients (pancreatic head cancer in 16 cases, duodenal papillary cancer in 27 cases, bile duct cancer in 8 cases, periampullary cancer in 2 cases, gallbladder cancer invading the pancreatic head in 1 case, intraductal papillary myxoma of pancreas in 6 cases, and mass-type chronic pancreatitis in 10 cases) were performed with end-to-side binding pancreaticojejunostomy were retrospectively analyzed, including large pancreas remnant (n=4). The main procedures included isolation of the pancreatic remnant, incising the jejunal wall and preplacing with seromuscular purse string suture around the incision, performing end-to side binding pancreaticojejunostomy.ResultsThe procedures were successful in all 70 patients. Postoperative complications included pancreatic fistula (n=3, 4.3%), of three patients cured with reoperation, jejunal loop decompression tube was not placed in 2 patients, and 1 patient had pancreatic fistula and bleeding on the eighth day after operation. One out of 3 patients developing abdominal hemorrhage which reoperation died of acute respiratory distress syndrome, 1 patient was cured with the vascular interventional hemostasis. Gastrointestinal anastomotic bleeding (n=1) and adhesive intestinal obstruction (n=1) were cured with reoperation, biliary leakage (n=1) was cured with conservative treatment.ConclusionEnd-to-side binding pancreaticojejunostomy is simple, safe and reliable.
Objective To summarize the preoperative CT three-dimensional reconstruction, and administration and visualization of indocyanine green (ICG) during ICG-assisted laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). Methods A 56-year-old female patient admitted to the Department of Biliary Surgery in West China Hospital in April 2022 was retrospectively analyzed. The patient was considered the possibility of benign tumor of pancreatic head, and underwent LDPPHR. Three-dimensional CT reconstruction was performed before operation, and ICG (5 mg) was injected intravenously preoperative and intraoperative to complete LDPPHR. Results Preoperative three-dimensional CT reconstruction can assist in judging the course and relationship of anterior and posterior pancreaticoduodenal arterial arch and surrounding main blood vessels. After intravenous injection of 5 mg ICG 24 hours before operation, the common bile duct at the upper edge of pancreas was clearly visualized, and the cystic mass was judged not to communicate with bile duct and pancreatic duct. But it was difficult to identify the pancreatic segment of the common bile duct in fluorescence mode, ICG 5 mg was injected intravenously during the resection stage, and then the common bile duct was obviously visualized. After the resection stage, injected ICG (5 mg) intravenously again. Within 1 min, the fluorescence of the duodenum was enhanced, which suggested that the blood perfusion of duodenum was well. The operative time was 280 min, the blood loss was about 200 mL. On the 10th day after operation, the patient developed transient gastrointestinal bleeding with bile leakage, which improved after symptomatic treatment and was discharged on the 19th day. Postoperative pathological examination diagnosed pancreatic serous cystadenoma. Conclusions Three-dimensional reconstruction and ICG assisted LPDDHR can successfully visualize and identify the blood vessels and bile ducts, and check the duodenal blood perfusion. Which can making the operation more accurate and visual is a powerful guarantee for LDPPHR to be carried out safely and effectively.
ObjectiveTo investigate the application of imbedding pancreaticojejunostomy in pure laparoscopic pancreaticoduodenectomy.
MethodsEighty-five cases of laparoscopic pancreaticoduodenectomy in our hospital from May 2014 to December 2015 were analyzed retrospectively. According with inclusion criteria and exclusion criteria, 78 cases were investigated. They were divided into pancreatic duct-to-jejunum mucosa pancreaticojejunostomy group as controlled group (n=42) and imbedding pancreaticojejunostomy (technique of duct-to-mucosa PJ with transpancreatic interlocking mattress sutures) group as modified group (n=36). The rates of pancreatic fistula, abdominal infection/abscess, bile leakage, delayed gastric emptying, gastrointestinal/intraabdominal hemorrhage, pulmonary infection, and incision infection were investigated as well as hospital stays and pancreaticojejunostomy time in two groups were compared.
ResultsThe rate of pancreatic fistula especially B to C grade pancreatic fistula in the modified group was obviously lower compared with which in the controlled group (8.3% vs. 31.0%, P < 0.05), pancreaticojejunostomy time ofmodified group was significantly shortened [(35.6±12.4) min vs. (52.8±24.6) min, P < 0.05] and total operative time also shortened [(322.4±23.6) min vs. (384.2±30.2) min, P < 0.05). There were no significant difference of the rates of abdominal infection/abscess, bile leakage, delayed gastric emptying, gastrointestinal/intraabdominal hemorrhage, pulmonary infection, ?incision infection, and hospital stays (P > 0.05)]. Conciusions The type of pancreaticojejunostomy has a significant impact on the rate of pancreatic fistula after laparoscopic pancreaticoduodenectomy. Imbedding pancreaticojejunostomy can decrease the rate of pancreatic fistula after operation, and shorten the pancreaticojejunostomy time and total operative time.
Objective To explore the feasibility of clinical application of hepatic artery （HA） or proper hepatic artery （PHA） anastomosing with superior mesenteric artery （SMA） and internal iliac vein （IIV） anastomosing with superior mesenteric vein （SMV） or portal vein （PV） in the extended pancreaticoduodenectomy combined with vascular resection．Methods The HA，PHA，SMA， SMV， PV， and IIV were dissected on 20 adult corpses， and the length， thickness，and lumen diameter of blood vessels were measured and compared with the results of multislice spiral CT scan，magnetic resonance angiography，or color Doppler in 25 patients with pancreatic head carcinoma．The extended pancreaticoduodenectomy was carried out on 5 patients of pancreatic head carcinoma with vascular invasion according to the mathcing results，and the reconstructions of HA or PHA with SMA and IIV with SMV or PV were performed．Results According to autopsy，HA-PHA was （5.50±1.50） cm in length，（0.20±0.01） mm in thickness，（5.02±1.32） mm in lumen diameter；and SMA was （4.00±1.00） cm in length，（0.21±0.01） mm in thickness，（6.05±1.06） mm in lumen diameter．The lumen diameter of left IIV，right IIV，and PV or SMV was （11.06±0.16） mm，（11.10±0.13） mm，and （11.56±0.20） mm，respectively．The thickness of left IIV，right IIV，and PV or SMV was （0.10±0.01） mm，（0.10±0.02） mm，and （0.10±0.02） mm，respectively．The multislice spiral CT scan，magnetic resonance angiography，color Doppler，and selective arteriography in vivo showed that the thickness and lumen diameter of HA-PHA and SMA were wider （0.1 mm and 0.3 mm） than those of the autopsy results，and there were no statistic significances （P＞0.05），but the length of HA-PHA was longer （1－2 cm） than that of SMA，and there was statistic significance （P＜0.05）. The survival of 5 patients with extended pancreaticoduodenectomy combined with PHA or SMA and IIV-PV/SMV resection and reconstruction was longer than that of palliative surgery patients or giving-up patients at the same period，and no long-term complications occurred．Conclusions The vascular invasion of pancreatic head carcinoma is not an absolute contraindication of radical pancreaticoduodenectomy．The survival of 5 patients with vascular invasion of pancreatic head carcinoma in this group is prolonged by extended pancreaticoduodenectomy combined with vascular resection and reconstruction as compared with palliative surgery group at the same period．HA，PHA，and IIV are the best autologous vascular alternative materials without more complications． Being familiar with regional anatomy will guide the surgeons in extended pancreaticoduodenectomy.
